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A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Select all.
- A. Keep the head of the bed elevated 30 degrees
- B. Massage the client's bony prominences often
- C. Apply cornstarch liberally to the skin after bathing
- D. Have the client sit on a gel cushion when in a chair
- E. Reposition the client at least Q 3 hr while in bed
Correct Answer: A, D
Rationale: The correct interventions (A and D) are crucial for preventing pressure ulcers in older adults. Elevating the head of the bed at 30 degrees helps reduce pressure on the sacrum and heels, key areas prone to pressure ulcers. Sitting on a gel cushion distributes pressure evenly, reducing the risk of skin breakdown.
Incorrect Choices:
B: Massaging bony prominences can increase friction and shear forces, leading to skin breakdown.
C: Cornstarch can create a moist environment, increasing the risk of maceration and skin breakdown.
E: Repositioning every 3 hours is insufficient for preventing pressure ulcers, as more frequent repositioning is needed to reduce prolonged pressure on the skin.
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A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all.
- A. A concave thoracic spine posteriorly
- B. An exaggerated lumbar curvature
- C. A concave lumbar spine posteriorly
- D. An exaggerated thoracic curvature
- E. Muscles slightly larger on his dominant side
Correct Answer: C, E
Rationale: Correct Answer: C, E
Rationale:
C: A concave lumbar spine posteriorly is expected in a young adult male due to the normal lordotic curve in the lumbar region for weight-bearing support.
E: Muscles slightly larger on his dominant side is an expected finding as asymmetry in muscle size and strength is common due to dominant limb use.
Incorrect Choices:
A: A concave thoracic spine posteriorly is not a normal finding and may indicate poor posture or spinal deformity.
B: An exaggerated lumbar curvature is not expected in a young adult male and may suggest a potential spinal issue.
D: An exaggerated thoracic curvature is not typical in a young adult male and may indicate abnormal spinal curvature.
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed & is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?
- A. Increase the oxygen flow.
- B. Assist the client to Fowler's position.
- C. Promote removal of pulmonary secretions.
- D. Obtain a specimen for arterial blood gases.
Correct Answer: B
Rationale: The correct answer is B: Assist the client to Fowler's position. This is the priority intervention because elevating the client to Fowler's position helps improve lung expansion and oxygenation by reducing pressure on the diaphragm and allowing better ventilation. Increasing oxygen flow (Choice A) may be needed, but positioning takes precedence. Promoting removal of pulmonary secretions (Choice C) is important but not the priority in this case. Obtaining arterial blood gases (Choice D) is important for assessing oxygenation status but can be done after ensuring optimal positioning.
A nurse is assessing the pain level of a client who has come to the ER reporting severe abdominal pain. The nurse asks the client whether he has nausea & has been vomiting. The nurse is assessing which of the following?
- A. Presence of associated symptoms
- B. Location of the pain
- C. Pain quality
- D. Aggravating & relieving factors
Correct Answer: A
Rationale: The correct answer is A: Presence of associated symptoms. By asking about nausea and vomiting, the nurse is assessing for other symptoms that may accompany the abdominal pain, providing crucial information for a comprehensive assessment. This helps in identifying potential causes, such as gastrointestinal issues. Other choices are incorrect because B: Location of the pain, C: Pain quality, and D: Aggravating & relieving factors focus solely on the characteristics of pain itself and not on associated symptoms.
A nurse is preparing info for a change-of-shift report. Which of the following info should the nurse include in the report?
- A. The client's input & output for the shift
- B. The client's BP from the previous day
- C. A bone scan that is scheduled for today
- D. The med routine from the med administration record
Correct Answer: C
Rationale: The correct answer is C: A bone scan that is scheduled for today. Including this information in the report is crucial as it alerts the oncoming nurse about the upcoming procedure, allowing them to plan and prepare accordingly. This is important for ensuring the client receives timely and appropriate care. The other choices are incorrect because: A (input & output) is important but may not be the priority for a change-of-shift report; B (BP from the previous day) is outdated information and may not be relevant for the current shift; D (med routine) should be documented in the client's chart and can be accessed by the oncoming nurse as needed.
A nurse is caring for a client who reports severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?
- A. Prodromal
- B. Incubation
- C. Convalescence
- D. Illness
Correct Answer: D
Rationale: The correct answer is D: Illness. In this stage, the client is experiencing noticeable symptoms such as severe sore throat, pain when swallowing, and swollen lymph nodes. This indicates that the infection has progressed to the point where the body is actively fighting off the pathogen, resulting in the manifestation of symptoms. The other choices are incorrect because: A: Prodromal stage is characterized by mild, nonspecific symptoms. B: Incubation stage is the period between exposure to the pathogen and the onset of symptoms. C: Convalescence stage is the recovery period after the illness when symptoms start to improve.